Pesticide Use Permit Application Instructions

Transcription

1 Pesticide Use Permit Application Instructions Section 1: General Information 1.1: Check the appropriate New Applicant or Renewal box. Pest management businesses who fail to submit their renewal application within 30 calendar days after the expiration date of their current permit shall be considered a New Applicant and are subject to the New Applicant fee. 1.2: Complete each field provided in it s entirety as it applies to your pest management business. 1.3: If the business physical address is the same as the business mailing address, enter SAME. 1.4: If application records are physically located at an address different than your business physical location, enter the address of your records. Otherwise, enter SAME. 1.5: Enter the name and contact information for a person with managerial authority with whom you would like our office to deal with regarding administrative and operational matters pertaining to your permit. Section 2: Permit Categories Applying For (Check all that apply) 2.1: Check the appropriate category box(es) being applied for. 2.2: If you qualify under the fee exempted categories, check the appropriate box in addition to the requested Non- Agricultural or Agricultural categories. 2.3: To qualify as a GRIC Member Owned Business, submit a photocopy of the OWNERS valid Gila River Indian Community Tribal Identification Card. Section 3: Current Arizona Licenses / Registrations / Permits #s (Business) 3.1: Enter the applicable license, registration or permit numbers for each item listed in the fields provided. 3.2: : Arizona Department of Agriculture 3.3: PMD: Pest Management Division 3.4: Submit a photocopy of each valid license, registration or permit identified in (3.1). Section 4: Current Certifications / License / Permit #s (Applicators) 4.1: Complete the fields provided for at least (1) one applicator employed by the business who will be conducting work within the Gila River Indian Community, while identifying the applicable certifications, licenses, or permit numbers. 4.2: PMD: Pest Management Division, Applicator License 4.3: PUP: Arizona Department of Agriculture, Pesticide Use Private 4.4: PUC: Arizona Department of Agriculture, Pesticide Use Commercial 4.5: AAP: Arizona Department of Agriculture, Aerial Applicator Pilot 4.6: GRIC CCAC: Gila River Indian Community Pesticide Control Office issued Community Certified Applicator certification which allows applicators to apply RUPs within the Community. 4.7: GRIC CAC: Gila River Indian Community Pesticide Control Office issued Community Applicator certification which allows applicators to apply GENERAL USE pesticides within the Community. 4.8: Submit a photocopy of each valid certification, license or permit identified in (4.1). Section 5: Pesticide Handlers & Workers 5.1: Complete the fields provided for EACH applicator/worker employed by the business who are subject to the Worker Protection Standard (40 CFR Part 170). 5.2: Enter the trainer s name by First initial then Last name, if known.

2 Pesticide Use Permit Application Instructions Section 6: Grower Requirements 6.1: Check the appropriate box regarding field maps. 6.2: If you are a new applicant or changes have taken place with your field location or designation, submit photocopies of maps showing the fields. 6.3: The map(s) shall have a unique identifier for each farm field and indicate the size of each farm field in acres. 6.4: If you utilize a Pest Control Advisor(s), enter their name in the field(s) provided and their Arizona Department of Agriculture PCA license number. Section 7: Financial Responsibility 7.1: Submit photocopies of proof of financial responsibility to cover claims of injury, illness, death, or property damage resulting from pesticide use. 7.2: Acceptable proof shall consist of a valid certificate of liability insurance or a surety bond endorsed in favor of the Community. 7.3: Coverages shall be at least $100,000 for property damage, $100,000 for personal death, injury or illness, and $100,000 for public liability. 7.4: Community governmental departments / enterprises, regulated growers and seed treaters are exempt from providing proof of financial responsibility. Section 8: Fees 8.1: Payment is accepted only by check or money order and shall be made out to GRIC Pesticide Fund. Section 9: Acknowledgement & Consent 9.1: Read, sign and date the Acknowledgement & Consent 9.2: Submission of your completed application, applicable photocopies and payment shall be remitted to: GRIC Department of Environmental Quality ATTN: Pesticide Control Office PO Box 2139 Sacaton, AZ 85147

3 New Applicant Renewal Pesticide Use Permit Application Section 1: General Information Business / Establishment Name: Owner: Mailing Address: City: State: ZIP: Physical Address: City: State: ZIP: Records Address: City: State: ZIP: Business Phone: Cell Phone: Fax: Contact Person s Name: Phone: Section 2: Permit Categories Applying For (Check all that apply) Non-Agricultural Categories Industrial / Institutional Wood Destroying Organism Management Ornamental & Turf Right of Way Aquatic Fumigation Wood Preservation Grower Seed Treatment Custom Applicator Agricultural Categories Fee Exempt Categories GRIC Government Department / Enterprise GRIC Member Owned Business Section 3: Current Arizona Licenses / Registrations / Permits #s (Business) Custom Applicator Air (CAA) Custom Applicator Ground (CAG) Custom Applicator Both (CAB) Seed Dealer Seed Labeler PMD Business License

4 Section 4: Current Certifications / License / Permit (Applicators) Applicator Name Categories PMD License # PUP # PUC # AAP # GRIC CCAC # GRIC CAC # First, Last Handler / Worker Name Section 5: Pesticide Handlers & Workers EPA Worker Verification # EPA Handler Verification # Expiration Trainer s Name First, Last W####### H####### DD/MM/YY F. LAST Section 6: Grower Requirements Maps Included No Changes to Maps Currently on File Pesticide Control Advisor s Name: First, Last PCA License Number: Pesticide Control Advisor s Name: First, Last PCA License Number:

5 Section 7: Financial Responsibility Insurance Firm Bond Expiration Property Damage Personal Death/I/I Public Liability Community government departments / enterprises, regulated growers and seed treaters are exempt from providing proof of financial responsibility. Section 8: Fees Section 9: Acknowledgement & Consent New Renewal Non-Agricultural Pest Management Business $ $ Agricultural Pest Management Business $ $ Grower & Seed Treatment $ $50.00 Community member owned businesses and GRIC government departments / enterprises are exempt from Pesticide Use Permit fees. I, the undersigned, certify that I am the owner or authorized representative of the business applying for a Pesticide Use Permit. I certify that the answers given herein are correct to the best of my knowledge and belief, with the understanding that false statements may result in application denial or civil penalties imposed to include but not limited to: permit suspension, revocation, and/or fines. By submitting this application, I am agreeing to submit to the enforcement authority of the Pesticide Control Office and to the jurisdiction of the administrative law judge, the Community Court, and the Community Court of Appeals for the express purposes of enforcement of GR-05-14: Pesticide Ordinance. Additionally, I acknowledge having received or am in possession of a copy of GR-05-14: Pesticide Ordinance and I understand my duties and responsibilities as contained within the Ordinance. Furthermore, by submitting this application, I acknowledge that any person, including a person who is not an Indian, who knowingly violates any provision of this chapter may be assessed a civil penalty; that any person under the criminal jurisdiction of the Community may also be subject to criminal prosecution; and that any person who is not a member of the Community may also be subject to GRIC Code Title Eight, Chapter One, Removal or Exclusion of Non-Members. Signature Date Section 10: For Official Use Only Date Received Received By Date Approved Date Denied Permit #